Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions

Abstract

Background: Bile duct injury (BDI) is a dreaded complication of cholecystectomy, often caused by misinterpretation of biliary anatomy. To prevent BDI, techniques have been developed for intraoperative assessment of bile duct anatomy. This article reviews the evidence for the different techniques and discusses their strengths and weaknesses in terms of efficacy, ease, and cost-effectiveness.

Method: PubMed was searched from January 1980 through December 2009 for articles concerning bile duct visualization techniques for prevention of BDI during laparoscopic cholecystectomy.

Results: Nine techniques were identified. The critical-view-of-safety approach, indirectly establishing biliary anatomy, is accepted by most guidelines and commentaries as the surgical technique of choice to minimize BDI risk. Intraoperative cholangiography is associated with lower BDI risk (OR 0.67, CI 0.61-0.75). However, it incurs extra costs, prolongs the operative procedure, and may be experienced as cumbersome. An established reliable alternative is laparoscopic ultrasound, but its longer learning curve limits widespread implementation. Easier to perform are cholecystocholangiography and dye cholangiography, but these yield poor-quality images. Light cholangiography, requiring retrograde insertion of an optical fiber into the common bile duct, is too unwieldy for routine use. Experimental techniques are passive infrared cholangiography, hyperspectral cholangiography, and near-infrared fluorescence cholangiography. The latter two are performed noninvasively and provide real-time images. Quantitative data in patients are necessary to further evaluate these techniques.

Conclusions: The critical-view-of-safety approach should be used during laparoscopic cholecystectomy. Intraoperative cholangiography or laparoscopic ultrasound is recommended to be performed routinely. Hyperspectral cholangiography and near-infrared fluorescence cholangiography are promising novel techniques to prevent BDI and thus increase patient safety.

Fig. 1

Forest plot of protective effect of IOC on BDI during cholecystectomy [–35]. OR odds ratio, BDI bile duct injury, IOC intraoperative cholangiography. *Unadjusted OR; **The data set of Fletcher et al. [84] is included in the study by Hobbs et al. [30]. ***The data set of Krahenbuhl et al. [85] is included in the study by Giger et al. [35]. Studies were weighted by the square root of the study size. Results are plotted on a natural logarithmic scale

Fig. 2

Passive infrared cholangiography in a porcine model depicting leakage of room temperature saline from the common bile duct (CBD) [70] (with permission from Springer Science + Business Media, © 2008)

Fig. 3

Near infrared fluorescen cholangiography during laparoscopic cholecystectomy [78]. A Cystic duct running parallel to common hepatic duct, B isolation of cystic duct from anterior side of Calot’s triangle, C isolation of cystic duct from posterior side of Calot’s triangle, D closure of cystic duct (with kind permission from John Wiley and Sons Ltd © 2010, all rights reserved)

Fig. 4

Hyperspectral cholangiography. A Near-infrared (NIR) laparoscopic hyperspectral image of the hepatoduodenal ligament in live anesthetized pigs. B An artery indicated by spectra with broad oxyhemoglobin peak and a small water peak at 970 nm. C A vein is identified by spectra containing a deoxyhemoglobin shoulder, a broad oxyhemoglobin peak, and a small water peak. D The common bile duct is associated with spectra containing a lipid shoulder and a prominent water peak [82] (with permission from Elsevier Inc., © 2008)